Properly identifying the cause and type of a patient’s skin condition involves a process of elimination known as differential diagnosis. Using this process, a health professional can take a given set of physical abnormalities, vital signs, health assessment findings, and patient descriptions of symptoms, and incrementally narrow them down until one diagnosis is determined as the most likely cause.
In this Lab Assignment, you will examine several visual representations of various skin conditions, describe your observations, and use the techniques of differential diagnosis to determine the most likely condition.
To Prepare
- Review the Skin Conditions document provided in this week’s Learning Resources, and select one condition to closely examine for this Lab Assignment.
- Consider the abnormal physical characteristics you observe in the graphic you selected. How would you describe the characteristics using clinical terminologies?
- Explore different conditions that could be the cause of the skin abnormalities in the graphics you selected.
- Consider which of the conditions is most likely to be the correct diagnosis, and why.
- Search the Walden library for one evidence-based practice, peer-reviewed article based on the skin condition you chose for this Lab Assignment.
- Review the Comprehensive SOAP Exemplar found in this week’s Learning Resources to guide you as you prepare your SOAP note.
- Download the SOAP Template found in this week’s Learning Resources, and use this template to complete this Lab Assignment.
The Lab Assignment
- Choose one skin condition graphic (identify by number in your Chief Complaint) to document your assignment in the SOAP (Subjective, Objective, Assessment, and Plan) note format rather than the traditional narrative style. Refer to Chapter 2 of the Sullivan text and the Comprehensive SOAP Template in this week’s Learning Resources for guidance. Remember that not all comprehensive SOAP data are included in every patient case.
- Use clinical terminologies to explain the physical characteristics featured in the graphic. Formulate a differential diagnosis of three to five possible conditions for the skin graphic that you chose. Determine which is most likely to be the correct diagnosis and explain your reasoning using at least three different references, one reference from current evidence-based literature from your search and two different references from this week’s Learning Resources.
Solution:
Comprehensive SOAP Template
Patient Initials: J.L Age: 41 years Gender: Male
SUBJECTIVE DATA:
Chief Complaint (CC): Rash #2
History of Present Illness (HPI): J.L, a Caucasian male patient aged 41 years presents to the clinic complaining of rashes on his abdomen and anterior chest. The rashes are numerous, round/oval, non-even, and red. Their onset was around 9 weeks ago. They have been increasing. He does not know of any alleviating or aggravating factors. The rashes are neither itchy nor painful. He has not used any medication to treat them
Current Medications:
Cetirizine 10mg PO q24hrs for seasonal allergies
Allergies: Seasonal allergies.
Past Medical History (PMH):
Has seasonal allergies. These are managed with cetirizine.
Past Surgical History (PSH): None
Personal & Social History: Works in a manufacturing company from Monday to Friday. He spends the weekend with family and friends. Occasionally takes alcohol. Denies smoking and illicit drug use.
Immunization History: All childhood vaccine up-to-date
Significant Family History:
Mother: diabetes mellitus type 2.
Father: Cherry angiomas
Review of Systems
Constitutional: Pt. denies fever, chills, night sweats, and abnormal weight gain/ loss.
HEENT:Pt. denies changes in vision, hearing, ringing ears, ear pain, nasal congestion, changes in smell, sore throat, neck pain, stiff neck, or teeth problems.
Breast:Pt.denies breast lumps, discharge, or tenderness.
Respiratory:Pt. denies cough, hemoptysis, dyspnea,or sputum.
Cardiovascular:Pt. denies chest pain, shortness of breath. Has no history of murmur,
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